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Auto Insurance Quote
This is a quote request form.  Submitting this form does not represent coverage or binding of coverages of any kind.  By submitting this form you agree to the above statement.
Many companies in Oregon, Washington, and Idaho use credit scoring in determining insurance premiums.
To determine which company is best suited to provide you the lowest rate, please indicate your credit status:
Location Information
Name
Address
City
State
Zip Code
  Email Address
Phone
General Information
Current Insurance
If you are currently insured,
Who is your carrier?
Policy Expiration Date / /
Are you a AAA Member?
Home Owner Status
Months of Continuous Coverage
Policy Wide Liability Coverages
Bodily Injury (BI)
In the event of an accident, BI protects you against bodily injury caused to third parties in an accident.
 
Property Damage (PD)
In the event of an accident, PD protects you against property damage caused to third parties in an accident.
 
Personal Injury Protection Limits (PIP)
PIP coverages may include lost wages and payments for child-care and other services you would normally perform, but are temporarily unable to, due to injuries caused by an accident.
 
Medical Pay Limits (MED)
MED coverages pay medical expenses for people covered under policy ("First Party" expenses).
 
Uninsured Motorists Bodily Injury Coverage Limits (UMBI)
UMBI coverage pays for injuries if you are hit by a driver with no auto insurance, and includes injuries from hit and run motorists.
 
Driver Information
 Driver 1  Driver 2  Driver 3  Driver 4
Full Name      
Age    
Sex    
Status      
Relation      
 Driver 1  Driver 2  Driver 3  Driver 4
Years at Residence      
If Any Accidents, Months Since Accident    
Years Licensed to Drive    
Months Licensed in This State    
Months Continuously Licensed    
Motor Vehicle Record
 Vehicle 1  Vehicle2  Vehicle 3  Vehicle 4
If you have had any tickets, accidents, or infractions in the last 3 years, describe them for each driver, and indicate the month and year of violation
Vehicle Information
 Vehicle 1  Vehicle2  Vehicle 3  Vehicle 4
Make of Vehicle      
Model of Vehicle      
(Example: Ford is the make, and Mustang is the model)
Year of Vehicle      
(Must be 4-digit year format)
Check All That Apply
 Vehicle 1  Vehicle2  Vehicle 3  Vehicle 4
Towing
(If Available)
Towing
(If Available)
Towing
(If Available)
Towing
(If Available)
Rental
(If Available)
Rental
(If Available)
Rental
(If Available)
Rental
(If Available)
New Car Loan
Coverage
New Car Loan
Coverage
New Car Loan
Coverage
New Car Loan
Coverage
Have Copy of
Registration
Have Copy of
Registration
Have Copy of
Registration
Have Copy of
Registration
Turbo-Powered
Vehicle
Turbo-Powered
Vehicle
Turbo-Powered
Vehicle
Turbo-Powered
Vehicle
Convertible Convertible Convertible Convertible
Leased Vehicle Leased Vehicle Leased Vehicle Leased Vehicle
Miles Driven Per Year    
Usage (Select Only One)    
Miles Driven to Work (One Way)    
 Vehicle 1  Vehicle2  Vehicle 3  Vehicle 4
Comprehensive Deductible    
Comprehensive provides coverage for most losses not covered by collision coverage.
Collision Deductible    
Collision is defined as losses you incur when your automobile collides with another car or object.
Uninsured Motorist Physical Damage    
UMPD coverage pays for damage done if your vehicle is hit by an uninsured driver.
Safety Devices
   Vehicle 1    Vehicle2    Vehicle 3  Vehicle 4
Select all that Apply
Airbag, Driver's Side Only Airbag, Driver's Side Only Airbag, Driver's Side Only Airbag, Driver's Side Only
Airbag, Both Sides Airbag, Both Sides Airbag, Both Sides Airbag, Both Sides
4-Wheel Anti-Lock Brakes 4-Wheel Anti-Lock Brakes 4-Wheel Anti-Lock Brakes 4-Wheel Anti-Lock Brakes
Automatic Seatbelts Automatic Seatbelts Automatic Seatbelts Automatic Seatbelts
Extra Equipment
The dollar amount you want for coverage of extra items. (CB, Radio, CD Player, etc.)
$ $ $ $
Educational Information
Are you currently a student?
If yes, what is your Grade Point Average?
 
This is a quote request form.  Submitting this form does not represent coverage or binding of coverages of any kind.  By submitting this form you agree to the above statement.

 

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